Valsalva Research Articles

Cutaneous phosphorylated-synuclein: an early diagnostic biomarker for pure autonomic failure

BackgroundPure autonomic failure (PAF) presents with progressive autonomic failure without other neurological features. Atypical presentations may lead to diagnostic uncertainty. We studied whether cutaneous phosphorylated-alpha-synuclein (p-syn) could distinguish between PAF,...

Enhanced Non-Invasive Diagnosis of Female Urinary Incontinence Using Static and Functional Transperineal Ultrasonography.

Background/Objectives: To investigate the utility of transperineal ultrasound in detecting stress urinary incontinence (SUI) and identify optimal anatomical and functional parameters. Methods: Thirty-four women presenting with SUI with or without pelvic organ prolapse between 2012 and 2016 were studied. The control group included patients without SUI who underwent surgery for mild gynecologic disorders or pelvic organ prolapse. The relationship between selected ultrasound parameters and SUI was determined. Results: Among the 20 variables measured in ultrasonography using 4 angles and the bladder-symphysis distance (BSD) values, we found that the difference in the BSD obtained at rest and during the Valsalva maneuver (odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.05-1.27, p = 0.004), the mean urethral diameter (UD; OR: 4.29, 95% CI: 2.07-8.83, p = 0.0001), and the occurrence of the funneling sign during the Valsalva maneuver (OR: 21; 95% CI: 6.1-71.9, p < 0.0001) were associated with urinary incontinence in the logistic regression analysis. The optimal cut-off point for BSD was >8 mm (area under the curve (AUC), 0.71; sensitivity, 91.2%; specificity, 56.8%; p = 0.001) and that for UD was >6 mm (AUC, 0.84; sensitivity, 82.1%; specificity, 73%; p < 0.001). Conclusions: Transperineal ultrasonography is a useful tool for detecting SUI. Our findings highlighted the utility of several sonographic parameters, mainly the urethral diameter, in the diagnosis of urinary incontinence.

Impact of the Valsalva manoeuvre on the choroid: A systematic review with meta-analyses.

A variety of daily activities can intentionally or unintentionally cause the Valsalva manoeuvre, which induces a physiological response of elevated peripheral venous pressure. Studies have speculated that it may ultimately affect the choroidal anatomy. This is particularly important from a clinical point-of-view since patients occasionally hold their breath while undergoing macular optical coherence tomography (OCT). In this study, we systematically reviewed the literature to understand the impact of the Valsalva manoeuvre on the choroid and conducted meta-analyses on the changes induced in the subfoveal choroidal thickness (SFCT) and the choroidal vascularity index (CVI). We searched 12 literature databases for studies in healthy participants undergoing Valsalva manoeuvre with choroidal OCT scans before and during the manoeuvre. Seven studies with a total of 444 eyes of 279 individuals were eligible for the review. The Valsalva manoeuvre led to a statistically significant but numerically small increase in the SFCT of 6.5 μm (95% CI: 1.6-11.4 μm; p = 0.01) and a statistically significant increase in the CVI of 1.48 (95% CI: 1.23-1.73; p = 0.0002). Thus, the Valsalva manoeuvre has a measurable impact on the choroid, and we recommend careful observation of how the patient sits and behaves behind the OCT scanner while scanning in order to allow accurate measurements of the choroid for diagnosis and monitoring.

Effect of Controlled Expiratory Pressures on Cerebrovascular Changes During Valsalva Maneuver

This study aimed to investigate the effects of Valsalva maneuver (VM) with the controlled expiratory pressures on vascular stiffness of common carotid artery (CCA) and cerebral hemodynamic changes using diagnostic ultrasonography. Twenty-seven healthy participants (mean and standard deviation of age = 22.78 ± 1.89) performed 30 and 40 mmHg VM. The right CCA stiffness index and pulse wave velocity (PWV) were measured before (PRE) and after (POST) VM. The peak systolic velocity (PSV), resistance index (RI), and heart rate (HR) were measured before (PRE) and after (POST1 and POST2 during the first and the second 15 s, respectively) VM. Near-infrared spectroscopy (NIRS) was utilized to measure regional oxygen saturation (rSO2) and oxyhemoglobin (HbO) on the left and right prefrontal cortex. Stiffness index decreased by 1.76 (p &lt; 0.001) from PRE to POST only after 30 mmHg VM. PWV decreased by 0.69 m/s (p &lt; 0.001, 30 mmHg) and 0.34 m/s (p = 0.022, 40 mmHg) in POST. Conversely, PSV increased by 5.36 cm/s (p = 0.031, 30 mmHg) and 4.77 cm/s (p = 0.04, 40 mmHg) in POST2. Increase in RI (p = 0.017) and decrease in HR (p = 0.003) occurred only after the 40 mmHg VM. Right HbO decreased after 30 mmHg VM (p = 0.023) from PRE to POST1, and right rSO2 increased after 40 mmHg VM (p = 0.036) from VM (during) to POST1. Both 30 and 40 mmHg VM showed a significant improvement in PWV and an increase in PSV. However, at 30 mmHg VM, a significant decrease in HbO was observed after VM owing to increased cerebral oxygen exchange, and at 40 mmHg VM, an rSO2 increase was observed after VM owing to high vascular pressure. Additionally, the increased pressure and rSO2 at 40 mmHg may have been caused by increased RI. The results indicated that the 30 mmHg VM was more effective on CCA stiffness than the 40 mmHg VM.

New onset of ataxic dysarthria with CSF overdrainage syndrome: A case report

Cerebrospinal fluid (CSF) overdrainage syndrome occurs when excessive CSF drainage from the cranial cavity results from a spinal CSF leak or overdrainage through a ventriculoperitoneal (VP) or lumboperitoneal (LP) shunt. Symptoms include severe orthostatic headache, worsening with sitting or standing but improving when recumbent. The headache is typically dull, throbbing, and bilateral and may be exacerbated by Valsalva maneuver, coughing, or straining. Additional symptoms can include dizziness, nausea, vomiting, gait disturbances, diplopia, back pain, and seizures. We present a case of overdrainage syndrome following LP shunt placement for idiopathic intracranial hypertension in a 38-year-old woman with Ehlers&amp;ndash;Danlos syndrome (EDS). One year post-surgery, she reported worsening headaches and nausea after prolonged upright positioning. Neurological examination revealed cerebellar dysfunction, including dysdiadochokinesia, intention tremor, and ataxic dysarthria. This condition gradually emerged 6 months post-LP shunt placement and was attributed to chronic overdrainage. After 1 day of observation, the patient underwent surgery to clamp the LP shunt outflow, resulting in overnight symptom resolution, including ataxic speech. This case underscores the importance of recognizing ataxic dysarthria in conjunction with low intracranial pressure syndromes, particularly in patients with EDS. It emphasizes the need to be aware of the diverse clinical manifestations of EDS and their relationship to altered CSF pressure syndromes.

Autoregulatory dysfunction in adult Moyamoya disease with cerebral hyperperfusion syndrome after bypass surgery

Cerebral hyperperfusion syndrome (CHS) is a serious complication after bypass surgery in Moyamoya disease (MMD), with autoregulatory dysfunction being a major pathogenesis. This study investigated the change of perioperative autoregulation and preoperative prognostic potentials in MMD with postoperative CHS. Among 26 hemispheres in 24 patients with adult MMD undergoing combined bypass, 13 hemispheres experienced postoperative CHS. Arterial blood pressure and cerebral blood flow velocity were perioperatively measured with transcranial Doppler ultrasound during resting and the Valsalva maneuver (VM). Autoregulation profiles were discovered in both the CHS and non-CHS groups using mean flow index (Mxa), VM Autoregulatory Index (VMAI), and a new metric termed VM Overshooting Index (VMOI). The CHS group had inferior autoregulation than the non-CHS group as indicated by VMOI on preoperative day 1 and postoperative 3rd day. Deteriorated autoregulation was observed via Mxa in the CHS group than in the non-CHS group on the postoperative 3rd and discharge days. Postoperative longitudinal autoregulation recovery in the CHS group was found in a logistic regression model with diminished group differences over the time course. This work represents a step forward in utilizing autoregulation indices derived from physiological signals, to predict the postoperative CHS in adult MMD.

C1 root decompression as a therapeutic target in non-suboccipital non-Valsalva related headache associated with Chiari I malformation

Headache is the most common symptom impacting the quality of life of patients with Chiari I malformation. While headaches typically present in the occipital or suboccipital regions, and induced by Valsalva maneuver, complex migraine-like headaches referring to frontal or orbital regions also occur. Our study explores the therapeutic potential of C1 nerve root decompression in addition to increasing intracranial compliance in patients with Chiari I malformation. We retrospectively analyzed cases operated on for Chiari I malformation, focusing on patients with non-suboccipital, non-Valsalva induced headaches. Preoperative and postoperative visual analog scale (VAS) scores and headache frequency were recorded. Surgical technique involved suboccipital craniectomy, C1 laminectomy, cerebellar tonsil reduction, and C1 root decompression. Twelve patients (10 females, 2 males) aged 22-52 were included. Preoperative mean VAS score was 8, which improved to 2 or less in 11 patients postoperatively. The mean headache frequency decreased significantly. Our findings suggest that C1 root compression contributes to atypical headaches in Chiari I malformation and that C1 root decompression may improve surgical outcomes.

Development and Validation of an Individualized Nomogram for Predicting Patent Foramen Ovale-Associated Stroke: Patent Foramen Ovale Morphology-Based Analysis.

We previously reported four patent foramen ovale (PFO) morphological types that influenced right-to-left shunt (RLS) grades. Herein, we aimed to study the relationship between PFO morphology and cryptogenic stroke (CS). We further developed a nomogram based on four PFO morphological types and functional parameters to guide clinicians in judging the risk of PFO-associated stroke. This was a retrospective observational study involving adult patients with PFO between January 2020 and November 2022. Patients were divided into a PFO-associated stroke group (CS group) and a group without cryptogenic stroke (non-CS group). Four types of PFO and RLS grades were analyzed. Nomograms were made to predict PFO-associated stroke using multivariable logistic regression analysis. The discrimination performance of the model was internally validated and assessed using the receiver operating characteristic. We enrolled 389 patients (male, 182 patients; female, 207 patients) with PFO, the mean age was 43.3±8.1 years. The derivation cohort comprised 293 patients (CS group, 186 patients; non-CS group, 107 patients). The predictive nomogram comprised PFO morphological types, interatrial septum (IAS) mobility distance, septum primum thickness, PFO channel length at rest, and contrast-transthoracic echocardiography (c-TTE) RLS grade during the Valsalva maneuver. A validation cohort was established (CS group, 61 patients; non-CS group, 35 patients). The model area under the curve (AUC) was 0.891 (95% confidence interval = 0.855-0.928) in the derivation cohort and 0.935 (95% confidence interval = 0.885-0.986) in the validation cohort. Calibration curve analysis showed that the nomogram had a C-index of 0.891 in the derivation cohort and 0.935 in the validation cohort. The decision curve analysis (DCA) indicated that the nomogram had clinical applicability. Adding four PFO morphological types improved the risk stratification capability for PFO-associated stroke. The nomogram can identify high or low-risk PFO individuals and select patients who will likely benefit from interventional device closure.

Anatomical Significance of the Patent Foramen Ovale by Real-Time 3D TEE in Cryptogenic Stroke and Migraine.

The transesophageal echocardiogram (TEE) is the standard imaging modality for confirming the presence or absence of patent foramen ovale. PFO is a flap valve depending on the pressure change between the left and right atrium, which can help determine whether to open. 3D-TEE was shown to optimize the visualization of PFO. There is a causal association between PFO and unexplained stroke. It seems that 3D-TEE can present a high-risk PFO morphological feature, which seems to show more than just being easier to open. In total, 134 consecutive patients with cryptogenic stroke or migraine who had suspected PFO and underwent c-TCD, TTE, and c-TEE were included in this study. TEE confirmed the PFO. The right-to-left shunt (RLS) grade of PFO at rest and abdominal compression Valsalva maneuver was detected by c-TEE. The long diameter of FO (1.74 ± 0.3vs. 1.60 ± 0.4, p = 0.039), the short diameter of FO (1.12 ± 0.3vs. 1.00 ± 0.3, p = 0.036), perimeter of FO (4.62 ± 0.7vs. 4.22 ± 1.0, p = 0.026), and area (1.80 ± 0.8vs. 1.35 ± 0.8, p = 0.05) of the FO were significantly larger in the larger RLS group. In group of CS, a larger proportion of Eustachian valve or a Chiari's network (14.3%vs. 3.5%, p = 0.036), a larger proportion of in the left funnelform (55.1%vs. 16.3%, p < 0.001), a longer length of the PFO tunnel (13.4 ± 4.4vs. 7.8 ± 2.5, p < 0.001), a lower IVC-PFO angle (16.4 ± 3.4vs. 20.3 ± 7.7, p = 0.001), a higher proportion of LA multiple exits of the tunnel (46.9%vs. 14.3%, p < 0.001). Multivariate regression analysis showed that male gender (HR: 4.026, 95% CI: 0.883-18.361, p = 0.072), age (HR: 1.076, 95% CI: 1.002-1.155, p = 0.045), the left funnelform (HR: 7.299, 95% CI: 1.585-33.618, p = 0.011), a longer length of the PFO tunnel (HR: 1.843, 95% CI: 1.404-2.418, p < 0.001) and multiple exits of the tunnel of LA (HR: 8.544, 95% CI: 1.595-45.754, p = 0.012) increased the risk of cerebral infarction. The cut-off value calculated by ROC for the diagnosis of high-risk PFO was that the length of the PFO tunnel was 12mm and the left funnelform combined with multiple exits of the left atrial (sensitivity was 92%, specificity was 90%). The area under the curve of the combined index versus PoPE score (0.932 vs. 0.736) relative to the RoPE score was statistically significant. TEE has shown outstanding advantages in displaying the specific morphological characteristics of PFO. The left funnelform, a longer length of the PFO tunnel, and multiple exits of the tunnel of LA are associated with an increasing risk of CS in anatomical PFO respect.

Consensus Statement: Postoperative Management after Balloon Dilation of the Eustachian Tube.

Balloon dilation of Eustachian tube (BDET) has been widely used as a minimally invasive treatment for obstructive Eustachian tube dysfunction (ETD). We used a Delphi consensus methodology to explore recommendations for clinical management of BDET in obstructive ETD. A Delphi panel of 26 expert physicians of otology participated in two rounds of anonymous, iterative questionnaires. Consensus is defined as ≥ 70% of panelists agree with recommendation and disagreement as < 70% agree. The responses from the Delphi study were analyzed using both the content validity ratio and Kendall's coefficient of concordance. The panel finally evaluated 26 topics, agreed 9 and did not reach consensus on 17 topics after 2 rounds. Although no consensus was reached on the postoperative follow-up period, a period of 12 months was most adopted. The Valsalva maneuver and questionnaire responses showed the highest agreement as postoperative assessment tools after BDET. Consensus was reached on some of the recommendations for the management of BEDT in obstructive ETD. The resultant agreement will provide directions for future research to describe standard postoperative management of BDET.

Orthostatic intolerance with tachycardia (postural tachycardia syndrome) and without (hypocapnic cerebral hypoperfusion) represent a spectrum of the same disorder.

Spectrum of chronic orthostatic intolerance without orthostatic hypotension includes postural tachycardia syndrome (POTS), with orthostatic tachycardia and hypocapnic cerebral hypoperfusion (HYCH), without orthostatic tachycardia. This study compared autonomic, cerebrovascular, and neuropathic features of POTS and HYCH. This retrospective study evaluated patients with orthostatic intolerance referred for autonomic testing. Analyzed data included surveys (Survey of Autonomic Symptoms, Compass-31, Neuropathy Total Symptom Score-6, Central Sensitization Inventory) and autonomic tests (Valsalva maneuver, deep breathing, sudomotor and tilt tests), cerebrovascular (cerebral blood flow velocity (CBFv) monitoring in the middle cerebral artery), respiratory (capnography), neuropathic (skin biopsies for assessment of small fiber neuropathy) and invasive cardiopulmonary exercise testing (iCPET). A total of 127 HYCH, 125 POTS, and 42 healthy controls were analyzed. Compared HYCH to POTS patients, there was no difference in the duration of symptoms, the prevalence of younger women, comorbidities, sensory and autonomic complaints, central sensitization syndrome, supine/standing norepinephrine levels, inflammatory markers and medical therapy except for gastrointestinal medication. Autonomic testing showed widespread but similar abnormalities in POTS and HYCH that included: reduced orthostatic CBFv and end-tidal CO2, preload failure (assessed in 16/19 POTS/HYCH), mild autonomic failure, and frequent small fiber neuropathy. HYCH and POTS are syndromes of orthostatic intolerance with cerebral hypoperfusion associated with reduced orthostatic cerebral blood flow, hypocapnia, mild autonomic failure and small fiber neuropathy of a similar degree and distribution; except for tachycardia in POTS. Similarities in peripheral domain abnormalities that affect heart rate suggest that orthostatic tachycardia in POTS is driven by the central nervous system overcompensation of orthostatic challenge. These findings provide additional evidence that HYCH and POTS represent a spectrum of the same disorder. Reduced orthostatic cerebral blood flow is a key unifying feature of HYCH and POTS.

Impact of party balloon inflation manoeuvre during saline contrast transthoracic echocardiography to detect a patent foramen ovale: multicenter registry study

Abstract Background Paradoxical embolism due to patent foramen ovale (PFO) can cause cryptogenic stroke. Agitated saline contrast transthoracic echocardiography (ASC-TTE) is an essential diagnostic tool for PFOs, and provocation using the Valsalva manoeuvre (VM) is necessary during the examination. Although VM is the standard method, assessing whether sufficient provocation has been achieved can pose challenges for the patients and examining staff. Conversely, a party balloon inflation manoeuvre (PBIM), which we previously reported (1, 2), offered a clear visual confirmation of provocation than conventional VM and showed effectiveness in cases of inadequate provocation. However, collective evaluation of PBIM by group remains unknown. Purpose This study aimed to demonstrate the superiority of PBIM over standard provocative methods, such as conventional or inferior vena cava compression VM, during ASC-TTE. Methods This multicentre registry study was conducted across eight high-volume institutions in Japan. A total of 117 consecutive patients (62.3% men, mean age; 56.2 ± 13.8 years, as of December 31, 2023) in whom paradoxical embolism was suspected and PFO was detected by transesophageal echocardiography, underwent PBIM and standard provocative methods during ASC-TTE. We compared them using a five-point microbubble grade (none or 1–4) using the right-to-left cardiac shunt as the primary endpoint (Figure 1). Results PBIM produced microbubble upgrading in 51 (43.6%, yellow panels in Figure 2), no change in 54 (46.1%), and down-grading in 12 (10.3%, blue panels in Figure 2) patients, compared to standard provocative methods. Wilcoxon paired analysis revealed that PBIM had a significantly larger microbubble grade than the standard provocative methods (median 3.0 interquartile range (IQR) [3.0–4.0] vs 3.0 IQR [1.7–4.0], p&amp;lt;0.001). If significant right-to-left shunt was grade ≥2, which was considered as the indication of catheter PFO closure, the pairwise McNemar’s test showed diagnostic performance of significant right-to-left cardiac shunt using PBIM improved from 75.2% to 91.5% (improvement rate; 16.3%, 95% CI; 8.4–24.0, p&amp;lt;0.001). Logistic regression analysis showed insufficient balloon inflation due to inexperience and risk of paradoxical embolism score independently associated with downgrading in PBIM after adjustments for age, sex, clinically relevant variables, and other echocardiographic parameters (odds ratio (OR); 24.0, 95% interquartile range (CI); 3.3–172.1, p&amp;lt;0.01 and OR; 0.60, 95% CI; 0.39–0.91, p&amp;lt;0.05, respectively). Conclusions PBIM significantly increased the microbubble grade compared to standard provocative methods. PIBM, using a simple tool, may provide an appropriate treatment strategy for patients with potential cryptogenic stroke attributed to PFO, especially those who are falsely diagnosed as negative for significant right-to-left cardiac shunts.Primary endpointsAgreement of 5-point microbubble grade

Transcatheter closure of atrial septal defect (ASD) in adult and paediatric population without transoesophageal echocardiography/general anaesthesia

Abstract Background Transcatheter device closure is the preferred therapeutic option for ostium secundum atrial septal defect(OS-ASD). Standard practice is to perform it under transoesophageal echocardiography(TEE) guidance. However, TEE is performed under general anaesthesia (GA) and leads to increases in cost, procedural duration, ICU stay, total hospital stays, risk of oesophageal injury and complications of GA. Transthoracic echocardiography(TTE) is an excellent alternative and prior studies have shown it to be a safe alternative in paediatric population. In current study we analysed safety and efficacy of TTE-guided device closure of OS-ASD in all comer population irrespective of age, weight, defect size. Methods The study enrolled all patients who underwent device closure of OS-ASD between March 2017 and December 2023. All procedures were performed under LA for adults and conscious sedation for children. The device was placed under fluoroscopy guidance and position were confirmed on TTE. Procedural success, device, defect size ratio, procedural time, fluoroscopy time, complications, intensive care unit/hospital stay duration were analysed and compared with our own experience of 125 patients with TEE-guided closures before switching to complete TTE-guided procedure(before 2017). Results 340 patients underwent TTE-guided device closure of ASD. Procedure success was 97.4% with acceptable risk of major complications. Three(0.8%) had embolization into pulmonary artery, successfully operated surgically. Two had tamponade requiring drainage. In 9 patients, device could not be deployed despite multiple attempts and approaches. All of these had defect size of &amp;gt; 34mm and deficient IVC rim along with shorter (other than aortic) rim. Findings were compared with our own previous experience of TOE guided closure (practised before 2017). Compared to TOE group, TTE group had significantly lower total procedural duration (75±4 vs. 28 ±1 min; p &amp;lt; 0.01), intensive care unit stay (24±10 vs. 10.5±1 h; p &amp;lt; 0.01), and hospital (48±12 vs. 25.5±4h; p &amp;lt; 0.01) stay duration. Fluoroscopic time was similar in both. There was no mortality in either group. Major complications were comparable, TTE-guided group had less post-procedure complications of vomiting and headache. Additional findings of less pre-procedure fasting duration and early commencement of post procedure oral intake were noted in TTE group. Conclusion TTE-guided device closure of OS-ASD is a safe and feasible in all-comer population in experienced hands. It can definitely negate the use of TEE except in very poor echo window. The added advantages include utilization of physiological variations in PV/LV pressure during cough, Valsalva manoeuvres in awake patients. It definitely reduces the procedural duration, cost of procedure and dependence on GA and trained transoesophageal echocardiographer.

Anatomical classification of patent foramen ovale before percutaneous closure

Abstract Introduction Anatomical characteristics of patent foramen ovale (PFO) vary a lot, potentially impacting the embolic risk, selection of the device and the final sealing results of the closure procedure. Objective To categorize the different PFO anatomies and evaluate the consequence on the type of device used and the incidence of residual shunt. Methods 624 consecutive patients who underwent PFO percutaneous closure with transoesophageal echocardiography (TEE) guidance were retrospectively reviewed. Four types of PFO were identified once a rigid wire was in place using per-procedural TEE. This new classification was based on the PFO sheathed tunnel’s length and width, presence of concomitant atrial septal aneurysm (ASA) or additional defect (ASD), width of the septum secundum (SS) and aortic enlargement (Figure 1). Type I, or "single PFO" was defined by the absence of ASA or ASD, a tunnel width ≤ 4mm, SS’s width ≤ 10mm and no aortic enlargement (i.e., aortic root diameter &amp;lt;21mm/m², distorted anatomy or scoliosis). Type II or "dominant septal aneurysm" was defined by the presence of an ASA, with a distinction between subtype IIa (long PFO tunnel with length ≥10mm) and subtype IIb (short PFO tunnel with length &amp;lt;10mm). Type III or "modified PFO" was defined by SS’s width &amp;gt; 10 mm, aortic enlargement, or severe scoliosis, and type IV or "multi perforated" was defined by the presence of a concomitant ASD or a multifenestrated septal wall. In case of concomitant criteria, the predominant order was IV, then IIb, then III. For each category, the presence of residual shunt was evaluated after Valsalva manoeuvres with contrast echocardiogram 6 months after the procedure. Results Our population had a median age of 51 [41-59] years and included 43.8% women. The type II PFO was the most frequently encountered, with 42% of the patients (Table 1). A total of 44 (7.1%) patients presented multiple types concomitantly (mostly type II and III). PFO occluders were the most implanted devices overall, particularly with type I and IIb, while ASD occluder were more frequently used with types IV and IIb. Cribriform/Uni™ devices were more frequently used with type IV. Large devices (i.e., left disc’s diameter &amp;gt;25 mm) were predominantly used with type III and IV, but scarcely employed with type I and II. Within type II anatomies, large devices were significantly more frequently used with type IIb. Fluoroscopy duration was significantly higher with type IV. At 6 months ultrasound evaluation, large right-to-left residual shunt was significantly more frequent with type IV anatomy and with patients presenting multiple types concomitantly (18/34 - 40.9%). No significant differences were observed regarding clinical outcomes during follow-up. Conclusion Based on specific anatomical characteristics, four types of PFO may be identified, presenting with increasing procedural complexity, and requesting specific closure devices.

Evaluation of clinical need, effectiveness, and safety of the first myosin inhibitor mavacamten in real world patients

Abstract Background Hypertrophic cardiomyopathy has a high burden of heart failure if obstruction in the left-ventricular outflow tract (HOCM) is present. Mavacamten is the first available myosin inhibitor specifically addressing the underlying pathophysiology of hypercontractility in HOCM. Based on positive results of respective approval studies, mavacamten is recommended for therapy of HOCM in recent ESC guidelines but clinical real world data are lacking. Methods In this ongoing study, consecutive patients with current or previous diagnosis of HOCM presenting at a single referral centre for hypertrophic cardiomyopathy from March 2023 to February 2024 were included and analysed by treatment modality. In patients initiating mavacamten therapy, clinical data of 4 weekly follow ups were assessed, including efficacy (NYHA class, LVOT gradient and biomarkers) and adverse events. Results A total of 72 patients were included (59.1 ± 13.0 years, 68% male). Mavacamten treatment was started in 30/72 (41.7%) patients, 3/72 (4.1%) were referred for transcatheter septal reduction therapy (SRT), and 39/72 (54.2%) did not require any escalation in their treatment due to low gradient with current treatment or few symptoms. Of the latter, 3/39 (7.7%) had previous SRT, 36/39 (92.3%) were stable on negative inotropic medication. The average age of patients selected for mavacamten therapy was 58.0 ± 13.0 years, 80% were male, and the average thickness of the interventricular septum was 18.8 ± 2.8 mm. 22/30 (73.3%) were on baseline therapy with beta-blockers, 3/30 (10.0%) with calcium channel blockers, 2/30 (6.7%) with both, and 4/30 (13.3%) had additional treatment with disopyramide. As shown in table 1, there was a significant decrease in the LVOT gradient under Valsalva maneuver observed 4 weeks after initiation of mavacamten treatment (p=0.006), while the reduction in peak exercise LVOT gradient was statistically significant after 8 weeks (p=0.02). Simultaneously, a significant decrease in Nt-pro-BNP levels was observed after 4 weeks of therapy (p&amp;lt;0.001). A significant drop in troponin T levels compared to baseline was only noted after 20 weeks of treatment (p=0.02). At baseline, 66.7% patients were classified as NYHA class III/IV, and 12.5% after 20 weeks of treatment. 75% of the patients improved ≥1 NYHA class after 20 weeks. Regarding adverse events, there was one case of ejection fraction dropping to &amp;lt;50%, which resolved after halting treatment. Additionally, there were two reports of dizziness and one reported syncope, all of which resolved without taking any actions. Conclusion In this real-world single centre HOCM cohort, 41.7% of patients had an indication for myosin inhibitor therapy. The safety and effectiveness in lowering the LVOT gradient and improving NYHA class were consistent with findings from the approval studies.

Relationship between parameters of the urethrovesical segment and quality of life in women with stress urinary incontinence

Aim of the study. To determine the relationship between ultrasound parameters of the urethro-vesical segment and the quality of life of women with stress urinary incontinence before and after surgical treatment. Materials and methods. We studied the quality of life and the severity of symptoms according to the UDI-6, I-Qol, IIQ-7, ICIQ-SF questionnaires, as well as ultrasound examination of the urethro-vesical segment in 40 women with stress urinary incontinence before and after surgery for the period 2023-2024. Correlation analysis among the listed indicators was performed. The mean age in the analyzed group was 49.7±9.7 years. Results and discussion. There was a significant improvement in postoperative quality of life scores for all the questionnaires used. There was a direct correlation between UDI-6 and urethral diameter in the Valsalva test, between IIQ-7 and the distance between the pubic symphysis and the bladder neck in the Valsalva test, the severity of symptoms according to the ICIQ-SF scale and the size of the posterior urethro-vesical angle at rest before surgery. After surgery, an inverse correlation was found between the distance from the pubic symphysis to the bladder neck in the Valsalva test and the data of the I-Qol questionnaire, as well as I-Qol and the values of the posterior urethro-vesical (β) angle in the Valsalva test. A direct correlation was found between the distance from the pubic symphysis to the bladder neck in the Valsalva test and the results of the IIQ-7 questionnaire, as well as between the β-angle value and the severity of symptoms according to the ICIQ-SF questionnaire. Conclusions. The results of the analysis confirmed the researchers' hypothesis that ultrasound parameters of the urethro-vesical segment correlate with the severity of symptoms and the level of quality of life in patients with stress urinary incontinence before and after surgical treatment.

Acute spontaneous vortex vein occlusion: clinical features, multimodal imaging and natural course

AimsTo describe the clinical features, multimodal imaging, treatments and natural course of acute spontaneous vortex vein occlusion.MethodsClinical data were collected on nine patients with acute vortex vein occlusion. The symptoms...

Ultrasound Evaluation of Onset Core Muscle Activity in Subjects with Non-Specific Lower Back Pain and Without Lower Back Pain: An Observational Case-Control Study.

Lower back pain (LBP) has been the leading cause of disability since 1990. Objectives: The main objective of this observational case-control study was to evaluate, using ultrasound, whether there were differences in the onset and ratio of core muscle contraction between subjects with non-specific chronic lower back pain and healthy subjects. Methods: A total of 60 participants (52% women), split between those with non-specific chronic lower back pain (n = 26) and healthy (n = 34) subjects, were recruited. Initial muscle contraction of the lateral abdominal wall, pelvic floor, lumbar multifidus, and respiratory diaphragm was measured using ultrasound. The abdominal drawing-in maneuver, contralateral arm elevation, the Valsalva maneuver, and voluntary contraction of the pelvic floor in seated and standing positions were performed. The muscle thickness of the lateral abdominal wall and lumbar multifidus and excursion of the pelvic floor and diaphragm at rest and during testing were also analyzed. Results: No differences were found between the groups in the initial contraction. Statistically significant differences were found in the following variables: diaphragm excursion (p = 0.032, r = 0.277) and lumbar multifidus ratio (p = 0.010, r = 0.333) in the standing-abdominal retraction maneuver; pelvic floor excursion (p = 0.012, r = 0.325) in the standing-contralateral arm raise; and transverse abdominis ratio (p = 0.033, r = 0.275) in the sitting-contralateral arm raise. A statistically significant interaction between the groups and body mass index was observed in resting diaphragm excursion (p = 0.018, partial eta squared = 0.096) during sitting-voluntary pelvic floor contraction. Conclusions: It cannot be concluded that there is a specific pattern of core activation in any of the groups. However, statistically significant differences were found in the contraction indexes of the lumbopelvic musculature.

Right-to-left-shunts in patients scheduled for neurosurgical intervention in semi-sitting position – a literature review based on two case scenarios

BackgroundNeurosurgery performed in the semi-sitting position provides advantages for certain procedures. However, this approach is associated with potential complications, particularly venous air embolism. Due to typically negative venous pressure at the wound site, air can be drawn into the veins. This risk is especially high in patients presenting with an intra- or extracardiac right-to-left-shunt. Transoesophageal echocardiography can be used to detect a patent foramen ovale or other possible pulmonary-systemic shunt before placing the patient in the sitting position.Case presentationIn this report, we present two young patients undergoing scheduled microsurgical vestibular schwannoma removal in a semi-sitting position who were diagnosed with congenital heart defects during routine perioperative assessment to detect possible intracardiac right-to-left shunts, using pre- and intraoperative transesophageal echocardiography (TEE) and additionally conducting an agitated saline bubble study under Valsalva manoeuvre. Patient A was diagnosed with a persistent left superior vena cava and Patient B with an unroofed coronary sinus (UCS). These findings confronted the anesthesiological and surgical teams with difficult individual decisions regarding further perioperative management.ConclusionsPerioperative transesophageal echocardiography is a diagnostic tool to both detect intraoperative position-related air embolisms and to rule out intracardiac right-to-left shunts, e.g. a patent foramen ovale, in order to decide for or against a (semi-)sitting position. Depending on the surgical circumstances a semi-sitting positioning of patients presenting with an intracardiac right-to-left-shunt, e.g. a PFO, can be feasible in individual cases if there is an implemented therapeutic algorithm to immediately terminate significant venous air entry. However, since certain other intra- or extracardiac right-to-left-shunts, such as here presented PLSVC or UCS, are rare, there is no definitive way of estimating the amount of entered air through detected shunts or anomalous vessels. Therefore, it is recommended to avoid a (semi-)sitting position in favour of a lateral or prone position for a patient undergoing intracranial surgery, once the perioperative TEE shows air bubbles in the left atrium or ventricle whose origins cannot be defined solely through TEE for certain in order to ensure patient safety by minimizing the risk of intraoperative paradoxical air embolisms.

Improvement of heart rate variability after metabolic bariatric surgery in Korean subjects with obesity.

Cardiovascular autonomic neuropathy (CAN) is a chronic complication of diabetes. As obesity is a major risk factor for CAN, we hypothesized that metabolic bariatric surgery (MBS) could improve CAN indices in Korean patients with obesity. Patients who underwent bariatric surgery between February 2020 and June 2022 were prospectively recruited. CAN was conducted once before surgery and again after surgery, using the Ewing method and heart rate variability (HRV) analysis (standard deviation of the NN interval [SDNN], root mean square of successive RR interval difference [RMSSD], and spectral analysis). A total of 47 patients were included. The mean age was 39.8 ± 8.7 years, 15 (31.9%) were male, and 26 (55.3%) had diabetes. Resting HR before surgery was 81.0 ± 12.3 bpm, which decreased significantly to 68.0 ± 9.3 bpm after surgery (P < 0.001). Changes in HR and BP according to the Valsalva maneuver, postural changes, and handgrip were not significantly different before and after surgery. However, SDNN significantly increased from 25.2 [15.1, 33.5] to 38.0 [25.4, 45.0] ms (P < 0.001), and RMSSD also significantly increased from 17.0 [9.2, 31.8] to 28.2 [15.3, 45.6] ms (P = 0.001). Both low-frequency power (LF) and high-frequency power (HF) increased significantly, and the LF/HF ratio significantly decreased from 2.1 ± 1.6 to 1.3 ± 1.3 (P = 0.010). Loss of weight, fat mass, and lean body mass were independently associated with improving the HRV variables. MBS improved HRV variables, and these changes were mainly associated with postoperative weight loss.